Obstetrical emergencies

OBSTETRICAL EMERGENCY MEANS IMMEDIATE

MANAGEMENT INCLUDING EARLY DETECTION

AND PROMPT ACTION FOR BETTER
OUTCOME OF PREGNANCY

1. obstetrical emergency
and its management
Prepared by
MOUMITA MANNA

2. DEFINITION
OBSTETRICAL EMERGENCY MEANS IMMEDIATE

MANAGEMENT INCLUDING EARLY DETECTION

AND PROMPT ACTION FOR BETTER
OUTCOME OF PREGNANCY .

3. THE IMPORTANT EMERGENCY CONDITIONS IN
OBSTETRICS
•1. VASA PRAEVIA.
•2. PRENSENTATION AND PROLAPSE OF THE UMBILICAL
CORD.
•3. SHOULDER DYSTOCIA.
•4. RUPTURE OF THE UTERUS.
•5.AMNIOTIC FLUID EMBOLISM.
•6.ACUTE INVERSION OF THE UTERUS.
•7.SHOCK IN OBSTETRICS.
•8. DIC

4. 1.VASA PRAEVIA
THE UNSUPPORTED UMBILICAL
VESSELS,
LIE BELOW THE PRESENTING PART
AND RUN ACROSS THE CERVICAL OS.

5. SIGNS AND SYMPTOMS OF VASA
PRAEVIA
1. FRESH VAGINAL BLEEDING,


2. FETAL DISTRESS,

6. MANAGEMENT OF VASA PRAEVIA

SIGNS OF FETAL DISTRESS (THE FETAL HEART RATE SHOULD BE
MONITORED)

STAT C.S

 SEND CORD BLOOD FOR HB ESTIMATION

IF THE BABY IS BORN ALIVE-
Resuscitation, haemoglobin estimation AND blood transfusion WILL BE
NECESSARY.

7. Patient -1
•A 38 weeks G4P3 lady presents with contractions. She is quite
distressed and thinks the baby is coming out. You perform a
pelvic examination and next to the head you feel a pulsatile
cord…

8. Patient -2
•A 38 weeks G4P3 lady presents with ROM and contractions. She
is quite distressed and thinks the baby is coming out. You can
see a cord like structure coming out of vagina…

9. 2. Cord Prolapse

•Presentation:
Cord in front of presenting part before the rupture of
membranes

•Prolapse:
Cord in front of presenting part after rupture of
membranes

10. Incidence
•Primigravida 0.45%
•Multigravida 0.66% (Risk ratio 2:3)
•Cephalic 0.3%
•Frank breech 0.9%
•Complete breech 5%
•Footling 10%
•Shoulder 15%
•Contracted pelvis 4-6 times

11. PREDISPOSING
FACTORS
MALPRESENTATION:-
TRANSVERSE
BREECH
COMPOUND PRESENTATION
HIGH HEAD:-
 MEMBRANES RUPTURE BUT FETAL HEAD IS HIGH.
PREMATURITY:-
LBW BABY <1500g.
POLYHYDRAMNIOS :-
CORD IS SWEPT DOWN IN THE GUSH OF LIQUOR.

12. PREDISPOSING FACTORS

TWINS OR MULTIPLE PREGNANCY

Long cord (90-100 cm)

PROM

CPD

13. Diagnosis
•Cord pulsations
•CTG shows variable decelerations
•Cord lying outside vulva
•USG – cord loops
•Fundal pressure
causes bradycardia
•Meconium stained
liquor

14. MANAGEMENT OF CORD
PROLAPSE
DISCONTINUE THE VAGINAL EXAMINATION to reduce the risk
of rupturing the membranes.
MONITOR CONTINUOUSLY THE FHR AND FETAL WELL-
BEING.
LIFT PRESENTING PART OFF THE CORD
INSTRUCT NOT TO PUSH
POSITION PATIENT
Knee chest
Exaggerated position
To minimise the cord compression.

15. Kneechest Position

16. Exaggerated Sim’s Position

17. CONT...
CORD PROLAPSE
BABY ALIVE
VAGINAL DELIVERY
NOT POSSIBLE
FIRST AID
DEFINITE-
SAESAREAN SEC.
CAESAREAN
SECTION
VAGINAL DELIVERY
POSSIBLE
VERTEX
FORCEPS OR
VENTOUS
BREECH
BY EXPERT HAND
BABY DEAD
USG AND VAGINAL
DELIVERY
MANAGEMENT OF
CORD PROLAPSE

18. 3.SHOULDER DYSTOCIA
IT OCCURS WHEN ANTERIOR SHOULDER BECOME
TRAPPED BEHIND THE SYMPHYSIS PUBIS, WHILE THE
POSTERIOR SHOULDER MAY BE IN THE HOLLOW OF THE
SACRUM OR HIGH ABOVE THE SACRAL PROMONTORY.

INCIDENCE:-
THE INCIDENCE VARY BETWEEN 0.37% - 1.1%

19. RISK FACTORS OF SHOULDER
DYSTOCIA
FETAL MACROSOMIA.
OBESITY MOTHER.
MATERNAL DIABETES.
POST MATURITY OF FETUS.
MULTIPARITY.
ANENCEPHALY.
FETAL ASCITES.

20. MANAGEMENT ( HELPERR)
Help – obstetrician, pediatrician
Episiotomy
Legs – elevate
Pressure - suprapubic
Enter vagina – (internal rotation).
Roll the woman over and try again.
Remove posterior arm

21. McRoberts Maneuver
•hyperflexion of maternal hips
•Increases intrauterine pressure
(1,653mmHg - 3,262 mmHg)
•Increases amplitude of
contractions
(103mm Hg to 129mm Hg)

22. Suprapubic Pressure
•direct posterior or oblique suprapubic pressure

23. Rubin’s Maneuver
•Adduction of the most accessible shoulder
•Moves the fetus into an oblique position and
decreases the bisacromial diameter

24. Woods’ Cork Screw Maneuver


•Abduct posterior shoulder exerting pressure on anterior
surface of posterior shoulder

25. Deliver posterior arm
(Barnum Maneuver)

•Grasp the posterior arm and
•Sweep it across the anterior
Chest to deliver

26. COMPLICATION OF
SHOULDER DYSTOCIA
FETAL COMPLICATION:-
ASPHYXIA.
BRACHIAL PLEXUS INJURY(ERB`S PALSY).
HUMERUS FACTURE, clavicular fracture.
STERNO-MASTOID HAEMATOMA.
HIGH PERINATAL MORBIDITY AND MORTALITY.
MATERNAL COMPLICATION :-
PPH.
CERVICAL, VAGINAL AND PERINEAL TEAR.
HIGH MATERNAL MORBIDITY RATE.

27. Patient - 3
A mother in second stage of labour suddenly complains of persistent
pain, and bleeding per vagina becomes profuse and the monitor shows
decelerations in fetal heart rate.

28. 4.RUPTURE OF UTERUS
DEFINITION:-
DISRUPTION IN THE CONTINUITY OF THE ALL UTERINE
LAYERS (ENDOMETRIUM, MYOMETRIUM, SEROSA) ANY TIME BEYOND 28
WEEKS OF PREGNANCY IS CALLED RUPTURE OF THE UTERUS.

ETIOLOGY:- RUPTURE OF THE UTERUS OCCURES-
A. DURING PREGNANCY.
B. DURING LABOUR.

29. Uterine Rupture
•1/2000 deliveries
Types:
•Complete
•Incomplete
•Rupture Vs Dehiscense of
C.S scar

31. CAUSES OF UTERINE RUPTURE
•Uterine injury sustained before current pregnancy
•C.S /hysterotomy/ repaired uterine rupture/ Myomectomy
•Uterine trauma - curette, sounds
• Sharp or blunt trauma - accidents, bullets, knives
•Congenital anomaly

32. CAUSES
Uterine injury during current pregnancy
•Before delivery
-- Intense spontaneous contractions
--Labour stimulation
--Intra-amnionic instillation
--Perforation by internal catheter
--External trauma - sharp or blunt
--External version
--Uterine overdistension - multiple pregnancy

33. Causes (cont…)
•During delivery:
Internal version
Difficult forceps delivery
Breech extraction
Difficult manual removal of placenta
Fetal anomaly
•Acquired:
Placenta increta / percreta
Retroverted uterus (sacculation)

34. SIGNS OF RUPTURE UTERUS
1.COMPLETE RUPTURE:-
SEVERE ABDOMINAL PAIN.
INCREASE MATERNAL PULSE RATE.
ALTERATION OF FETAL HEART RATE.
FRESH VAGINAL BLEEDING.
STOP UTERINE CONTRUCTION.
FETUS BECOME PALPABLE IN ABDOMEN.
INTRAPARTUM FETAL DEATH.
MOTHER`S BECOME COLLAPSE AND SHOCK.

35. CONT..
2.INCOMPLETE RUPTURE:-
SHOCK DURING THIRD STAGE OF LABOUR
DUE TO BLOOD LOSS.
ABDOMINAL PAIN.
POSTPARTUM HAEMORRHAGE FOLLOWING
VAGINAL DELIVERY.

36. MANAGEMENT OF UTERINE RUPTURE
•Total Hysterectomy
•Sub total hysterectomy
•Simple repair

37. Patient 4
•A pregnant mother on oxytocin induction suddenly becomes
short of breath and tachypneic. Vital signs drop and the
patient goes into asystolic arrest.

38. Amniotic Fluid Embolism
•Incidence: 1 in 3,500 to 1 in 80,000
•Amniotic fluid enters the maternal circulation and reaches
pulmonary capillaries
•Through a tear in amnion and chorion
•Opening in maternal circulation
•Increased intrauterine pressure

39. Amniotic Fluid Embolism

40. Risk factors
•Multiparity
•Large fetus
•Meconium in amniotic fluid
•Intrauterine fetal death
•Precipitate labour
•Placental abruption
•Intrauterine catheter
•Rupture of uterus

41. MANIFESTATIONS
•Phase I : Pulmonary vasospasm
Hypoxia
Hypotension
Cardiovascular collapse
•Phase II: Left ventricular failure
Pulmonary edema
Hemorrhage
Coagulation disorder

42. MANAGEMENT OF AMNIOTIC
FLUID EMBOLISM
•Intubation + Mechanical ventilation
•CVP monitoring
•Blood transfusion + I.V. Fluids
•Dopamine 2-20mg/kg/min
•IV Digitalization (0.1 - 1.0mg)
•Prostaglandin
•Morphine
•Aminophylline
•Hydrocortisone

43. Patient - 3
•Mother in third stage of labour. Using the controlled cord traction, the
midwife tries to deliver the placenta. Unfortunately, notices the
descent of uterus instead of placenta.

44. ACUTE INVERSION OF THE UTERUS
IT IS AN EXTREMELY RARE BUT A LIFE THREATENING COMPLICATION
IN THIRD STAGE OF LABOUR IN WHICH THE UTERUS IS TURENED
INSIDE OUT PARTIALLY OR COMPLETELY.


 CLASSIFICATION:- ACCORDING TO SEVERITY-
FIRST DEGREE- THE FUNDUS REACHES THE INTERNAL OS.
SECOND DEGREE- THE BODY OF THE UTERUS IS INVERTED TO THE INTERNAL OS.
THIRD DEGREE- THE UTERUS, CERVIX, VAGINA ARE INVERTED AND ARE VISIBLE.

45. Degrees of uterine inversion
•1st - Dimpling of fundus,
remains above internal os

•2nd - fundus passes through the
cervix, but lies inside vagina

•3rd - (complete) Endometrium
with or without placenta is
outside the vulva

46. Uterine Inversion
•1/20,000 deliveries
Causes:
•uterine atony (40%)
•Increase in intra abdominal pressure
•Fundal attachment of placenta (75%)
•Short cord
•Placenta accreta
•Excessive cord traction

47. Management
•Uterine relaxant (terbutaline 0.25 mg IV followed by 2 g
of MgSO
4 over 10 min)
•Treat hypovolumeia
•Without placenta: Repositioning

48. Uterine Inversion

49. Management(cont…)
•With placenta: Do not remove placenta
•Replace uterus
•Bimanual compression
•Hydrostatic pressure (O’Sullivan 1945)
•Start oxytocin
•Laparotomy

50. 7.SHOCK IN OBSTETRICS
DEFINITION:-
A STATE OF CIRCULATORY INADEQUACY WITH POOR
TISSUE PERFUSION RESULTING IN GENERALISED CELLULAR HYPOXIA.


IMPORTANT SHOCK IN OBSTETRIC:-
THE MAIN SHOCK IN THE OBSTETRICS ARE-
1.HYPOVOLAEMIC SHOCK.
2.SEPTIC SHOCK.

51. 1. HYPOVOLAEMIC SHOCK
DEFINITION:-
THE RESULT OF A REDUCTION
IN INTRAVASCULAR VOLUME SUCH AS IN
SEVERE OBSTETRIC HAEMORRHAGE.

52. PRESENTING FEATURES OF
HYPOVOLUMIC SHOCK
ORGAN SYSTEM EARLY LATE
BP NORMOTENSIVE OR
HYPOTENSIVE.
HYPOTENSION
PULSE TACHYCARDIA. SAME.
RESPIRATION NORMAL TACHYPNOEA.
RENAL OLIGURIA ACUTE RENAL
FAILURE
SKIN COLD & CLAMMY COLD & CLAMMY.
MENTAL STATUS NORMAL DISORIENTATION

53. MANAGEMENT
HYPOVOLAEMIC SHOCK
MAINTAIN AIRWAY- OXYGEN 6 TO 8 L/M.

RESTORE CIRCULATORY VOLVME - 2LIT OF
CRISTALLOID THEN COLLOID. NOT MORE THEN 1000 -1500ml IN A DAY.

WARMTH.
ARREST HAEMORRHAGE.

54. SEPTIC SHOCK
DEFINITION:-
IT OCCURS WITH A SEVERE GENERALISED
INFECTION.

55. PRESENTING FEATURES
OF SEPTIC SHOCK
ORGEN SYSTEM EARLY LATE
BP NORMOTENSIVE OR
HYPOTENSIVE
HYPOTENSIVE
PULSE TACHYCARDIA TACHYCARDIA
RESPIRATION TACHYPNOEA,
PULMONARY
EDEMA.
TACHYPNOEA
SKIN WARM COLD & CLAMMY.
RENAL OLIGURIA ACUTE RENAL
FAILURE.
MENTAL STATUS NORMAL DISORIENTED

56. MANAGEMENT OF
SEPTIC SHOCK
REPLACEMENT OF FLUID VOLUME.
IDENTIFY THE SOURSE OF INFECTION.
INFECTION SCREENING SHOULD BE CARRIED
OUT- VAGINAL SWAB, URINE AND BLOOD
CULTURES
ASEPTIC TECHNIQUE SHOULD BE MAINTAIN.
ANTIBIOTIC SHOULD BE GIVEN.

57. DISSEMINATED INTRAVASCULAR
COAGULIPATHY
•DIC is a serious disorder in which the proteins that
controls blood clotting becomes overactive.

58. CLINICAL FEATURES OF DIC
 Unexplained spontaneous bleeding from any site e.g
 oozing of blood
Briusing
Epistaxis
Hematuria
Hematema formation
PPH

59. MANAGEMENT OF DIC
•Eliminate underlying cause
•Blood transfusion
•FFP transfusion
•Fibrinogen
•Anti-fibrinolytic agents

60. NURSE’S ROLE IN INTRAPARTUM
CARE
NURSE MIDWIFE
COMMUNICATOR
EDUCATOR
CARE
GIVER
MANAGER
ADVOCATE
COUNSELLOR CO ORDINATOR
RESEARCHER